Nasogastric and Intestinal Tubes

Nasogastric Tubes

A nasogastric tube is a narrow bore tube passed into the stomach via the nose. It is used for short- or medium-term nutritional support, and also for aspiration of stomach contents – eg, for decompression of intestinal obstruction.

Key Points

Prior to insertion, position the client in High-Fowler’s position if possible.

Use a water-soluble lubricant to facilitate insertion

Measure the tube from the tip of the client’s nose to the earlobe and from the nose to the xiphoid process to determine the approximate amount of tube to insert to reach the stomach

Flex the client’s head slightly forward; this will decrease the chance of entry into the trachea

Insert the tube through the nose into the nasopharyngel area; ask the client to swallow, and as the swallow occurs, progress the tube past the area of the trachea and into the esophagus and stomach. Withdraw tube immediately if client experiences respiratory distress

Secure the tube to the nose; do not allow the tube to exert pressure on the upper inner portion of the nares

Validating placement of tube.

Aspirate gastric contents via a syringe to the end of the tube

Measure ph of aspirate fluid

Place the stethoscope over the gastric area and inject a small amount of air through the NGT. A characteristic sound of air entering the stomach from the tube should be heard

Characteristics of nasogastric drainage:

Normally is greenish-yellowish, with strands of mucous

Coffee-ground drainage – old blood that has been broken down in the stomach

Bright red blood – bleeding from the esophagus, the stomach or swallowed from the lungs

Intestinal Tubes

Provide intestinal decompression proximal to a bowel obstruction. Prevent/decrease intestinal distention. Placement of a tube containing a mercury weight and allowing normal peristalsis to propel tube through the stomach into the intestine to the point of obstruction where decompression will occur

Types of Intestinal Tubes

Cantor and Harris Tubes

Approximately 6-10 feet long

Single lumen

Mercury placed in rubber bag prior to tube insertion

Miller-Abbot Tubes

Approximately 10 feet long

Double lumen

One lumen utilized for aspiration of intestinal contents

Second lumen utilized to instill mercury into the rubber bag after the tube has been inserted into the stomach

Nursing Implications

Maintain client on strict NPO

Initial insertion usually done by physician and progression of the tube may be monitored via an X-ray

After the tube has been placed in the stomach, position client on the right side to facilitae passage through the pyloric valve

Advance the tube 2 to 4 inches at regular intervals as indicated by the physician

Encourage activity, to facilitate movement of the tube through the intestine

Evaluate the type of gastric secretions being aspirated

Do not tape or secure the tube until it has reached the desired position

Removal of the tube depends on the relief of the intestinal obstruction

May be removed by gradual pulling back (4-6 inches per hour) and eventual removal via the nose or mouth

May be allowed to progress through the intestines and expelled via the rectum.

How to Insert a Nasogastric (NG) Tube

Check physician’s order.

Check client’s identaband and if able have client state name.

Discuss procedure to client.

Provide privacy.

Gather equipment.

Position client at 45 degree angle or higher with head elevated.

Wash hands and don clean gloves.

Provide regular oral and nasal hygiene.

Remove gloves and wash hands.

Position client for comfort.

Document procedure.

Confirming Placement of NGT

1. Assess pH

Aspirating fluid to assess its pH content and appearance and confirm correct placement is another important part of the insertion protocol. Gastric contents will always be acidic (< 5.6 pH), while fluid from the pulmonary tract will be alkaline (>6 pH)

However, measuring the pH level alone does not differentiate between respiratory and gastrointestinal placement of the tube; both sites can have high pH values (> 6).The pH test has no value if the patient is receiving acid suppression medication.

2. Assess color of gastric fluid

One study investigated the use of visual inspection of feeding tube aspirates in identifying feeding tube location in the respiratory or GI tracts. It was concluded that observation of the visual characteristics of feeding tube aspirates is of little value in differentiating between respiratory and GI placement.

Gastric fluid is usually grassy green or colorless, with shreds of off-white to tan mucus, while intestinal fluid tends to be golden and translucent. Pleural fluid is typically off-white or pale yellow.

3. Though it has been common practice, auscultation is not a reliable indicator of correct NGT placement.

Be aware that the common practice of instilling air into the tube via syringe and auscultating over the stomach for a “swoosh” sound is not a reliable indicator of proper tube placement since an NG tube in the respiratory tract can transmit a similar sound.

Studies indicate that auscultation is not a reliable method to differentiate gastric and respiratory placement

4. X-ray

The gold standard for confirming tube placementis an X-rayespecially in a critically ill, elderly, dysphagic or unconscious patient. Many facilities require radiologic confirmation before using the NG tube for feeding or medication administration. It’s also essential when your evaluation of aspirated fluid is inconclusive.

5. Other clinical methods of detecting tube placement may be unreliable

In cases where the patient may have suppressed gag or cough reflexes such as in the situations like decreased level of consciousness or neurologic debilitation, the absence of coughing or choking after placement of the tube may be misleading.

Once tube placement is confirmed, the nurse must then secure the tube to keep it from becoming dislodged. This may be done using aa split-tape method, which involves tearing off about four inches of tape and splitting it lengthwise to about the halfway point. After creating tabs on the split ends, tape the un-split end to the end of the nose and crisscross the split ends around the tube.

Removing a Nasogastric Tube

Objectives

To check if the patient can tolerate oral feeding.

Contraindications

Continuing need for feeding/suction.

After Care

Discard the disposasble equipment used.

Wash your hands.

Position the patient in a comfortable or in his desired position.

Charting

Record date of removal of nasogastric tube.

Record client’s response.

Record measurement of drainage.

Equipment

Tissues

Plastic disposable bag

Bath towel or disposable pad

Clean disposable glove

Nursing Alert: Removal is easier with the patient in semi-Fowler’s position.

Record removal of nasogastric tube, client’s response, and measurement of drainage.

Facilitates documentation and provides for comprehensive care.

Irrigating a Nasogastric Tube

A nasogastric tube is irrigated regularly to determine/ensure the patency of the tube. Learn how to irrigate a nasogastric tube (NGT).

Objective

To ensure the patency of the nasogastric tube.

Indication

Stomach contents fail to flow through tube.

Contraindication

Some tubes are maintained by airflow, not normal saline solution.

Nursing Alert: Connect proper end (main lumen) of double lumen tube to suction. The short lumen is an airway, not a suction-drainage tube. With double-lumen tube, if main lumen is probably blocked, clear the main lumen, then inject up to 60 cc of air through the short lumen above the level of the stomach where the end of the main lumen is located.

Assist client to semi-Fowler’s position unless this is contraindicated.

Minimizes risk of aspiration.

Check placement of NG tube;

Attach Asepto or Toomey syringe to the end of tube and aspirate gastric contents.b. Place 10mL-50ml of air in syringe and inject into the tube. Simultaneously, auscultate over the epigastric area with a stethoscope.

Ask client to speak.

The tube is in the stomach if its contents can be aspirated.b. A whoosing sound can be heard when the air enters the stomach through the tube.